Can somebody look this over please

[Liebchen]

Hello,

I am required to do three (3) care plans in order to pass clinical. I just want to throw out there, that I am in OB and peds. this quarter, and I know I have found my niche. Not pediatrics, I hate pediatrics, but I adore Ob. Anyway, my assignment consisted of three care plans. One teaching, one mother, and one baby. I did my mother, and passed. Would somebody mind looking over this information and letting me know if I am on the right track with the baby care plan, please?

Diagnosis 1: Risk for imbalanced nutrition r/t poor feeding behaviors AEB newborns inability to properly latch.

Diagnosis 2: Risk for infection r/t circumcision.

Diagnosis 3: Risk for respiratory distress R/T thermoregulation

Diagnosis4: Ineffective thermoregulation r/t immaturity AEB newborns inability to maintain body temperature above 97.5

Priority DX: Ineffective thermoregulation r/t immaturity AEB newborns inability to maintain body temperature above 97.5

Long term goal: Newborn will maintain thermal homeostasis with axillary temperature of 97.8 - 98.6

Short term goal: Newborns temperature will increase to 97.8 within one hour.

(another possible goal) mother will be able to return demonstrate understanding of kangaroo care and other methods of warming baby, as well as demonstrate her ability to assess babes axillary temperature by discharge.

( I only need two goals, one long-term and one short-term).

Interventions:

1.) Nurse will assess newborns axillary temperature q 30 mins. until temperature stabilizes at 97.8.

2.) Nurse will monitor for signs of respiratory distress and other symptoms of thermoregulation (lethargy etc.) q 30 mins. until newborns temperature stabilizes at 97.8.

3.)Nurse will maintain environmental temperature between 89.6 and 92.3.

4.) Nurse will teach mother proper technique for kangaroo care.

Of course I would put rationales beside each intervention

Outcome: Goal met: Baby obtained adequate temperature and mother demonstrated knowledge of importance in keeping baby warm, kangaroo care and ability to assess axillary temperature.

Ok, tell me, honestly and brutally how I did. I really feel it is important to learn this well, so I want to know everything I did wrong, please.

Also, we have to do a concept map, and although I have just downloaded a program to help me. I have no idea what things to put on a concept map and how to connect it to this care-plan. Can anybody give me a few suggestions to get me started?

Thank you

[Double-Helix, BSN, RN]

I think it looks good. My only "problem" is that I think you left out some important interventions. All your interventions relate I monitoring, teaching, and the environment. None of them include what you are doing to do for the baby to warm him up. Skin to skin time with mom? Warm blankets? Swaddling? Cover his head? Remove him from drafts, areas near windows, air conditioners and cold surfaces? Use a warmer? Room temperature or warm formula if bottle feeding? All of those are important interventions that will help warm the baby now- much faster than controlling environmental temp, monitoring and teaching.

But good work otherwise!

[Liebchen]

Yes, I can see why that would be much more important.

I also have to give 3 interventions for each goal, so I did not complete my assignment. Thank you for your advice. I really appreciate it.

[Liebchen]

corrections have been made. does this look better?

diagnosis 1: risk for imbalanced nutrition r/t poor feeding behaviors aeb newborns inability to properly latch.

diagnosis 2: risk for infection r/t circumcision.

diagnosis 3: risk for respiratory distress r/t thermoregulation

diagnosis4: ineffective thermoregulation r/t immaturity aeb newborns inability to maintain body temperature above 97.5

priority dx: ineffective thermoregulation r/t immaturity aeb newborns inability to maintain body temperature above 97.5

long term goal: newborn will maintain thermal homeostasis with axillary temperature of 97.8 - 98.6 by time of discharge.

short term goals:

1.) newborns temperature will increase to 97.8 within one hour.

2.) mother will be able to return demonstrate understanding of

kangaroo care and other methods of warming baby, as well as

demonstrate her ability to assess babes axillary temperature by

discharge.

3.) newborn will be free of s/s of respiratory distress r/t

thermoregulation ( increased respirations, lethargy) by the time

baby warms to 97.8.

interventions:

1.1)nurse will place baby in gradient warmer.

1.2)nurse will move baby away from drafts and cold surfaces

1.3)nurse will make sure baby’s head is covered and swaddled when baby is away from warmer.

1.4)nurse will maintain environmental temperature between 89.6 and 92.3 (f) in newborns room.

2.1.) nurse will teach mother the effects of heat loss on baby.

2.2.) nurse will demonstrate to mother how to apply kangaroo care.

2.3.) nurse will teach mother how to assess axillary temp of newborn.

3.1.) nurse will assess newborn respirations q 30 minutes while baby

is at risk, and q 4 hours afterwards.

3.2.) nurse will monitor vital signs q 30 minutes while baby is at risk

and q 4 hours afterwards.

3.3.) nurse will monitor for s/s of respiratory distress r/t

thermoregulation ( lethargy, increased respirations, hypoxia and low bg levels.)

[Double-Helix, BSN, RN]

Looks great! I'll also add that, for Diagnosis #3, the rist for resp distress is not related to thermoregulation, exactly. It is because a cold core temp can slow brain function, including the resiratory center in the hypothalamus. So the wording should really state something like: Risk for respiratory distress related to decreased functioning of the brain secondary to hypothermia.

:-)

[Liebchen]

Thank you!! I will make that correction. I really appreciate your input.